Tag Archives: study review

This study found that hormone therapy reduced symptoms of psychological distress, although surgery had no further effect.

However, this conclusion is undercut by the fact that one person committed suicide during follow-up,* treatment did not reduce the prevalence of suicide attempts, and 17% of the people surveyed after treatment reported suicidal thoughts.

There are also areas where the methodology of the study could be improved.

Finally, the data on the percentages of suicide attempts is confusing. See the end of this review for details on the data.

Over 90% of patients said that they were happier and felt better about their body after treatment, but 17% reported that they had suicidal thoughts.

The improvement in psychological symptoms happens after hormone therapy. Surgery did not cause a significant change in psychopathology, although patients reported slightly more symptoms after surgery than after hormone therapy.

When asked, 57.9% of patients said that they experienced the most improvement after hormone therapy, 31.6% experienced the most improvement after surgery, and 10.5% experienced improvement just from being diagnosed.

After treatment, the average scores of psychopathology were similar to the general population.

After hormone therapy, none of the average subscale scores were different from the general population. However, after surgery, the group’s average scores for sleeping problems (p=0.033) and psychoticism (p=0.051) were higher than the general population.

These results raise some important questions.

What can we do to reduce suicide, suicide attempts, and suicidal thoughts in transgender people who have transitioned?

Why didn’t the percentage of suicide attempts go down when people were reporting fewer symptoms of depression?

Why didn’t surgery improve the mental well-being of the patients?

There were also a couple of important methodological questions that the authors did not discuss.

Combining the results of different treatments

As often happens, the study lumped together trans men (born female) and trans women (born male). The treatments for trans women and trans men involve different medications and surgeries. It is possible that androgens and estrogens have different effects on mood. Similarly, it might be that some surgeries are more beneficial to mental health than others or that some surgeries are more stressful than others.

The participants in the study were 46 trans women and 11 trans men. The authors do not discuss whether they differed in their mental health symptoms or social well-being. Nor do they give information on the gender of the people who completed the questionnaires at follow-up.

The study does not specify exactly what medications and dosages were used for the hormone therapy. They do not say exactly what surgeries the patients got.

Missing Data

As with many longitudinal studies, they did not have follow-up data on all of the participants due to incomplete questionnaires. In addition, one participant did not complete a questionnaire at the beginning of the study.

Thus, 56 people completed a questionnaire about their mental health before treatment, but only 47 people completed the questionnaire after hormone treatment. The authors then compared the average scores on the baseline questionnaires to the averages on the questionnaires after hormones.

It is possible that this would lead to a bias in the data. For example if depressed people were less likely to complete follow-up questionnaires, the average for the follow-up questionnaires would show fewer symptoms of depression than the average for the initial questionnaires.

The authors do not discuss whether the people who did not complete the questionnaires after hormone therapy were significantly different from those who did.

Leaving suicide out of the results

The person who committed suicide was not included in the study; if they had been it might have distorted the data. Presumably their responses at baseline would have increased the average score for symptoms of depression, but without a follow-up questionnaire for them, symptoms of depression would appear to go down. Leaving them out makes the results clear – symptoms of depression went down among everyone else.

At the same time, without data on the person who committed suicide during follow-up, it is not fully accurate to say that symptoms of depression went down after treatment. For at least one person it doesn’t make sense to talk about symptoms of depression going down.

Suicide during follow-up is part of the results of this study. It is relevant to the question of whether or not people felt better after transition. When someone commits suicide during a study, this needs to be part of the discussion. When did they commit suicide? Were they depressed before transition? Did they regret the surgery? Did they say they were depressed during or after transition?

Not talking about the suicide is disrespectful to the person who died. It leads to possibly false conclusions about the effects of transition. And it stops us from being able to figure out what we can do to prevent future suicides – do we need to give people more therapy before medical treatments? should some people not get surgery? do we need to give people more therapy after surgery?

Back to the questions raised by the study

What can we do to reduce suicide, suicide attempts, and suicidal thoughts in transgender people who have transitioned?

Clearly, medical transition is not enough. It does not prevent suicide, suicide attempts, or suicidal thoughts. It does not even reduce the prevalence of suicide attempts.

As far as I know, this is the only study that has followed a group of people with gender dysphoria during treatment and collected data on suicide attempts.

We need more research to figure out how to prevent suicide and suicide attempts among transgender people after transition. It might also help if we knew more about what was going on in this study.

When exactly were the suicide attempts – after hormones or after surgery? When exactly did the person commit suicide? Does this reflect regret related to the surgery itself or something else?

Were there any gender differences in the suicide attempts?

Were there any differences in the specific treatments given to the people who attempted suicide? Were there any problems in the outcomes of the treatments?

Did the same people attempt suicide before and after transition?

Did the people who attempted suicide say they were depressed? Had they been diagnosed with mental health issues? Were they getting counseling?

Do we know of things that went wrong in the lives of the people who attempted suicide?

Do some people need more counseling and evaluation before transition? Should we adapt the hormonal doses or surgeries for different people? Do we need to give additional support after transition? Are there alternatives to transition that would better help some people deal with gender dysphoria?

At this point all we know is that we can not rely on medical transition to prevent or reduce suicide attempts among transgender people.

We need to know more.

Why didn’t the percentage of suicide attempts go down when people were reporting fewer symptoms of depression?

The results of this study are somewhat confusing. People reported that their symptoms of depression and psychological distress went down after transition. In addition, the vast majority of people who had transitioned said that they felt better – they were happier (93%), less anxious (81%), more self-confident (79%), and their body-related experience improved (98%). Only 2 people said they were more anxious and 1 less self-confident. Only 2 said that their overall mood was similar.

So why did 7 people (17.6%) report that they had suicidal thoughts? Why were there 4 suicide attempts?

Were the people who had suicidal thoughts so unhappy to start with that an improvement in their mood still left them suicidal? Perhaps they had even more suicidal thoughts before transition – but the prevalence of suicide attempts was not affected by transition.

It’s possible that the group’s average scores for depression are in the normal range while a few individuals are miserable. On the other hand, the group has an above average number of suicide attempts and suicidal thoughts. According to an Emory University website“It is estimated that 3.7% of the U.S. population (8.3 million people) had thoughts of suicide in the past year, with 1.0% of the population (2.3 million people) developing a suicide plan and 0.5% (1 million people) attempting suicide.” In this study, 17.6% of the group reported suicidal thoughts at the moment of follow-up. The suicide attempt percentage was 9.8% at follow-up.

We are looking at a group of people with elevated levels of suicidal thoughts and suicide attempts – how does that fit with questionnaires that find a normal level of symptoms of depression?

Are we seeing accurate reports of how people feel? Are people minimizing their problems when they fill out questionnaires after treatment?

The authors of the study do not discuss the apparent contradiction between suicide attempts and suicidal thoughts one the one hand and an improved mood on the other.

The authors do point out that the percentage of suicide attempts at the beginning of the study was lower than in other studies of transgender people. It may be that the participants in this study had fewer problems than most transgender people; for one thing they are a group that is able to access medical care. However, that does not answer the question of why for this particular group of people transition did not change the prevalence of suicide attempts.

We need more research into what is going on here. We need to be able to identify people who may attempt suicide or feel suicidal after transition so we can help them.

Why didn’t surgery improve the mental well-being of the patients?

We don’t know and we need more research to answer this question. However, here are a few possibilities:

Possibility #1 – Return to regular life

In their discussion, the authors suggest that there might be an initial euphoria after beginning hormones that wears off later on. In addition, after surgery, people might be “again confronted with stigma and other burdens.”

In other words, the improvement after hormone therapy is higher than the improvement will be in the end. There is still an improvement later on, but the initial level of euphoria isn’t going to last. If this is true, it would be important information for people who are transitioning so that they don’t have false expectations of what life will be like after transition is complete.

Possibility #2 – Surgery is not the best treatment for everyone

The authors also suggest that further studies should look at exploring the idea that some patients might want hormones without surgery.

It may be that surgery is not the best treatment for everyone with gender dysphoria. Perhaps some people would have been better off with just hormone therapy.

Previous studies have found that about 3% of people who have had genital surgery regret it, so we would expect one or two people out of 50 to regret their surgery. Perhaps they are depressed and this affects the group average.

Possiblity #3 – Effects of surgery

It is also possible that some people had post-surgical depression and that this affected the results.

Perhaps some people were still recovering from surgery and did not feel well (the study included people 1 to 12 months after surgery). In particular, this might lead to the increase in sleeping problems found in the study.

Perhaps some people were dealing with complications of surgery.

Perhaps the hormonal changes after surgery affected people’s moods.

Possibility #4 – People were already happy

On the other hand, perhaps by the time people get surgery, they are already happy due to counseling, hormones, and social transition.

Perhaps if people had been forced to stop with hormone therapy alone, they would have become unhappy. As the authors point out, it may have made a difference that they knew they were going to be able to get surgery.

Possibility #5 – Surgery doesn’t affect mental health

It may simply be that surgery does not improve mental health. At this point, we do not have proof that it does.

In the end, we just don’t know.

Further studies are needed to determine if surgery is helpful and who should get it. Perhaps the authors of this study can use the data they already have to address this question.

The authors talk about the prevalence of suicide attempts before and after transition, but they don’t talk about the time periods they are looking at. The authors say that the prevalence of suicide attempts was unchanged, but they don’t explain when the suicide attempts took place before treatment. It makes a big difference if they are comparing three years before transition to three years afterward or if they are comparing a lifetime before transition to the average 3 year follow-up period – a follow-up that took place 1-12 months after surgery.

In addition, the actual data on suicide attempts is confusing. In Table 3, the authors list the prevalence of suicide attempts as 9.4% at presentation and 9.3% at follow-up. However, in their discussion they say the suicide attempt percentages were 10.9% initially and 9.8% at follow-up.

Looking at Table 3, there were 5 attempts in a group of 54 people which would give a percentage of 9.26%, a number that doesn’t match either of the ones given by the authors. In addition, there were 4 attempts in a group of 42 people which would give 9.52%, another number that doesn’t match.

The percentage they gave at baseline in Table 3 seems to be 5 out of 53 people, while the percentage at follow-up seems to be 4 out of 43. Perhaps one of the 54 people didn’t answer the question on suicide attempts in the first set of questionnaires. But where does the additional person come from in the second set of questionnaires? If they are including the person who committed suicide in the suicide attempts, wouldn’t the number of people used to calculate the percentage before treatment be 54 or 55, not 53?

None of this explains why they would list different numbers in their discussion. Perhaps there were some suicide attempts by the same person that were included in one set of numbers but not the others? The table talks about the prevalence of suicide attempts while the discussion talks about the percentage.

This is a 2010 study of the functional and cosmetic outcomes of the surgical techniques used at a German clinic. They followed 50 trans women who had surgery between May 2001 and April 2008. The surgeries were all performed by the same surgeon who had extensive surgical experience.

Before surgery, all the patients had completed a two year “real life” test and had been recommended for surgery by two independent psychiatrists. They had been on hormones for at least one year, although they stopped taking hormones a month before the surgery.

The patients were sent a questionnaire to follow-up on sexual function and patient satisfaction with the surgery. All 50 patients completed the questionnaire; the mean follow-up time was 3 years.

Outcomes of Surgery

Regrets:

One person regretted the surgery and became clinically depressed. They attempted suicide twice and had not fully recovered two years later.

The patient was 24 years old and the authors suggest that the ideal age for surgery is 30 years old. They also recommend thorough evaluation and good counseling before surgery.

This is consistent with other studies that found a regret rate after surgery of 3-4%. In a group of 50 people getting the surgery, you would expect one or two people to wish that they had not had the surgery.

The patient regretted the surgery 3 days after the operation.

Complications:

6% had bleeding after surgery

4% required operative revision due to the bleeding (two of the three who had bleeding)

10% had shrinkage of the vagina which could be corrected by a second surgical intervention

4% had a minor bulge in the anterior vaginal wall which could be easily fixed with simple excision

There were no post-operative rectocele (bulge of the rectum into the vagina) or urethrovesical fistulae.

The authors of the study say that the incidence of surgical complications was comparable to the data in the literature.

The 6% of patients with bleeding that they report is better than the 10% reported by a United Kingdom clinic in this review.

Their rate of complications is considerably better than this 2001 study at a different German hospital which reported that “Major complications during, immediately and some time after surgery occurred in nine of the 66 patients (14%), including severe wound infections in six, a rectal lesion in three, necrosis of the glans in three and necrosis of the distal urethra in one. Minor complications, e.g. meatal stenosis in seven patients, occurred in 24 (36%) of patients.”

They do not report any problems with narrowing of the urethra, which is also an improvement over the 3-4% reported by the clinic in the Untied Kingdom.

They do not report any problems with pulmonary embolisms or fistualae between the rectum and vagina. These are problems that are relatively rare and you might not expect to see them in a group of only 50 people; the review from the United Kingdom reported a rate of 2 in 1000 pulmonary embolisms with 1 death. They also reported a rate of 6 in 800 rectal fistulae.

Minor complications:

6% subcuntaneous hematoma that did not require any further therapy (i.e. they had a ruptured blood vessel causing a lump or bruise under the skin)

In comparison, the United Kingdom clinic reported an operative time of 120-150 minutes, while the 2001 German study reported a mean time of 6.3 hours with a range of 4-9 hours.

Satisfaction with results at follow-up

Appearance:

10% of the patients were dissatisfied with the appearance of their labia

90% were satisfied with the appearance of their genitals

We need more research on how to construct labia that are satisfactory for all trans women.

Depth of Vagina:

20% were dissatisfied with the depth of their vagina

80% were satisfied with the depth of their vagina

4% were still dissatisfied with their vagina after a second operation

Of the ten women who were dissatisfied with the depth of their vagina, eight had a new operation to augment the vagina. Of the women who had the second operation, two were still dissatisfied (25%). Perhaps the secondary operation could be improved.

We need to know more – why were 20% dissatisfied with the depth of their vagina? What can be done to ensure that all trans women have vaginas that are deep enough?

How deep were the vaginas at follow-up? Were there some women whose vaginas were not deep who were satisfied anyway?

Sexual Pleasure:

5% of the trans women having regular sexual intercourse experienced pain during intercourse; 84% of the trans women were having regular sexual intercourse

70% of the trans women reported achieving clitoral orgasm

The authors are not clear here, but it looks like 30% of the trans women who had this surgery are unable to achieve orgasm. This is a serious problem; they should have addressed it more fully.

Were some of the women not attempting orgasm? Did everyone answer the question?

At one point the authors say, “84% reported having regular sexual intercourse, of whom 35 had clitoral orgasm” – that would change the numbers to 35 out of 42 women which would be better (although it would still leave 17% of the sexually active women not having orgasms). On the other hand, they also say, “Of the 50 patients, 35 (70%) reported achieving clitoral orgasm.”

As it stands, it looks like a large percentage of trans women are not having orgasms after surgery. That would be a problem and worthy of more discussion in the results. The ability to orgasm is an important, vital aspect of the outcome of these surgeries.

In addition, doctors and surgeons need to address the problem of pain during intercourse. Is there something trans women can do themselves to reduce the pain? Can the surgeries be improved in this area?

From their Discussion and Conclusions:

“The incidence of surgical complications was comparable to the literature data. The most common complication (10%) in the follow-up was shrinkage of the neovagina. In all cases a second surgical correction was necessary to definitively solve the problem. In all patients vaginopexy to the sacrospinous ligament was carried out, reducing the rate of neovaginal prolapse as described in the literature.

After 3 years, 49 patients were satisfied and did not regret or had doubts about having undergone sexual reassignment surgery. The only exception was a 24-year old patient who, 3 days after the operation, regretted his decision. After that, he developed a strong depression which needed psychological therapy. Two years after surgery, the patient had still not recovered completely and had attempted suicide twice.

We agree with Rehman and Melman that the best age to undergo sexual reassignment surgery is 30 years, an age that enables patients to adjust socially and sexually, increasing the possibility to develop attractiveness and allowing the patients to mature in dealing with new life stresses. Moreover, before undergoing such surgery, it is our opinion that all patients at all ages need deep and intensive psychological examination and must be informed about all the functional and cosmetic risks associated with this operation and, above all, about the impossibility of regretting the decision and returning to their natural gender.

With improvements in surgical technique over the years, male-to-female gender-transforming surgery can assure satisfying cosmetic and functional results, with a reduced intra- and postoperative morbidity. Nevertheless the experience of the surgeon and the center remains a central important aspect for obtaining optimal results.”

The full article includes graphic pictures of surgery as well as details of their technique; you can get it at the link below.

This is a 2007 review of research on gender reassignment surgery. It shows clearly that we need more research in this area.

The research is not strong enough to evaluate the efficacy of gender reassignment surgery in general. In addition, we do not have a way to evaluate particular surgeries.

From the abstract:

“The evidence concerning gender reassignment surgery in both MTF and FTM transsexism has several limitations in terms of: (a) lack of controlled studies, (b) evidence has not collected data prospectively, (c) high loss to follow up and (d) lack of validated assessment measures. Some satisfactory outcomes were reported, but the magnitude of benefit and harm for individual surgical procedures cannot be estimated accurately using the current available evidence.”

The authors reviewed all the articles they could find on gender reassignment surgeries from 1980 onwards. The review took place in October and November 2005.

The great strength of this review is that they looked at individual surgical procedures. Too often studies lump together all gender reassignment surgeries and then evaluate whether or not they were effective. It is possible that some surgeries are more helpful for people’s mental well-being than others. In addition, some surgeries may have better physical outcomes or fewer risks than others. The physical outcomes could certainly affect people’s mental well being as well.

They did not find enough good studies looking at individual surgeries; there is a great need for more such studies. We need to know what are the complications and problems with various surgeries. Are some techniques better than others? Do some medical centers have better physical outcomes than others?

Only a few of the studies reported on patients’ well-being, mental health, or satisfaction; these studies had the same methodological weaknesses as the others.

This is the main finding of the review – we don’t have great data and we need further research. You can read more about some of the specific surgical procedures here.

The authors discuss the quality of research and directions for future research; I have included their discussion below.

Discussion

In the first section concerning MTF surgical procedures, 38 published papers met the inclusion criteria (23 case series and 15 case studies) with an additional 13 papers excluded (four case series, three case studies, four reviews, one prospective non-randomized controlled study, one expert opinion). The level of included evidence was of poor quality. There was a clear lack of randomized controlled evidence and only one excluded study included a control group comparison. No studies met the inclusion criteria for labiaplasty, orchidectomy or penectomy procedures. A large amount of evidence is available reporting vaginoplasty and clitoroplasty procedures. Some complications have been reported. All the studies report, to various degrees, satisfactory outcomes in terms of being able to have penetrative sexual intercourse and achieving sexual fulfilment.

In the second section concerning FTM surgical procedures, 44 published papers met the inclusion criteria (26 case series, 17 case studies, one cohort study) with an additional 19 papers being excluded (seven reviews, five expert opinions, four case series, three case studies). The majority of included evidence was of poor quality. Many of the studies reported good satisfactory outcomes with few complications for each of the individual procedures. The main outcomes reported were the ability to perform penetrative sexual intercourse and achieve orgasm. Another key factor requested by many FTM patients was the ability to void whilst standing. Whilst successful results were reported by many studies for phalloplasty procedures, an inability to perform sexual penetration due to the construction of a small phallus was a common problem reported following the metoidioplasty procedure. Some of the FTM core surgical procedures are frequently completed along with other surgery, making it difficult to assess the effectiveness of each procedure alone. Furthermore, the assessment of effectiveness is also confounded by the lack of controlled evidence, unclear outcome measures, and a reliance on case series and case studies.

Six previous reviews have reported the clinical effectiveness of GRS. Six reviewed evidence in MTF patients and three of these also reviewed evidence in FTM patients. Of these, three were systematic reviews. These earlier reviews provide a summary of approximately 172 individual studies. Two recent unpublished reports provided a brief summary of some of the reviews. Several key points were raised in these previous reviews. The first related to the quality of the evidence and study design. Concerns were raised about the lack of randomized controlled evidence, the majority of evidence involved case studies and case series, with few studies using group comparisons, standardized measures or the follow up of participants. A second concern related to the validity of findings. Many studies involved a combination of different surgical procedures. Thirdly, there was concern about the validity of outcome measures. Despite many reports of positive outcomes of patients, there was little consensus of how to measure effectiveness. The large range of outcomes reported across studies makes it difficult to accurately evaluate the overall outcomes of individual surgical procedures.

Several previous reviews reported a controlled study which compared 20 patients having immediate surgery with 20 patients awaiting surgery for penectomy, orchidectomy and the construction of a neovagina. The remaining studies reflect lower grades of evidence, and had further problems in their design such as selected patient groups, retrospective analysis and losses to follow up. Conclusions from the reviews are understandably tentative, but highlight improvements in patients across most studies, although 10–15% of patients with transsexism who undergo GRS have poor outcomes.

The quality of evidence included in this review has been poor due to the lack of concealment of allocation, completeness of follow up and blinding. As well as the fundamental limitation in study design, several other issues regarding the interpretation of the evidence are worth consideration. Firstly, all the reviews, and many of the individual studies within them, examine different types of GRS. The Mate-Kole study, for example, is essentially an evaluation of three surgical techniques. Clearly, trying to reach a robust conclusion about GRS as a whole is not possible when the combination of techniques varies across studies. Secondly, the patient populations within, and across studies, are heterogeneous and we have little idea about the referral, diagnosis, assessment and selection processes that precede inclusion within the studies. Consequently, Brown concludes that a lengthy differential diagnosis and a specialized approach to interviewing gender dysphoric patients are needed. Thirdly, the choice of outcome measures varies across studies, with very little use of validated health-related quality of life (QOL) measures. This complicates further our ability to draw conclusions, and also limits the commissioners’ ability to identify studies that use outcomes that are relevant to their role. Finally this review has focused on a subset of surgical procedures that are used within this field. Whilst these are considered to be the most routine, it is recognized that other procedures are currently used and these too need to be critically appraised in future reviews.

No published evidence on cost-effectiveness was found. Best and Stein speculate that some cost offsets are possible following surgery due to the reduced need for psychiatric and hormonal treatment, but no evidence is available for this. The lack of generic QOL measures means that measures of cost-effectiveness that can be used to assess value for money relative to other healthcare interventions are not possible.

When trying to consider all of the evidence together, there is a dilemma regarding its interpretation. Reviews of heterogeneous patient groups and interventions clearly give the greatest depth of evidence, but give little in the way of specific information that is of use to purchasers. In contrast, studies of individual techniques have a more limited evidence base but allow us to focus on specific clinical questions with more consistent reporting. But these provide information on purchasing decisions that are less realistic, as some procedures are unlikely to be purchased in isolation. In between these extremes, are sets of studies that investigate various combinations of multiple procedures, but matching these studies to the activity of different providers and patients, is extremely complex.

Taking this reasoning further, some would argue that assessment of GRS in isolation is difficult to interpret, as it is the final step in a longer treatment process. This is more contentious, as many patients do not reach the point of referral for surgery and many do not wish to undergo any surgery. Also, taking this argument to its extreme would require studies of the effectiveness of treatment from initial diagnosis to the end of post-surgical follow up; such studies do not exist.

Despite these difficulties in interpretation of review evidence the conclusion about the strength of evidence regarding GRS appears clear: little robust evidence exists.

Future research

There is a need for good quality controlled trials based on clearly defined diagnosis and assessment criteria.

An important consideration for future studies is how best to evaluate the effectiveness of a surgical procedure. One possibility is assessment of patient satisfaction and regret following surgery. More importantly is the need for standardised measures to assess the outcome of surgery. One suitable method, which has received limited research, is the use of QOL measures in samples before and after GRS. Rakic et al.investigated several aspects of QOL after GRS in 32 patients with transsexism (22 MTF, 10 FTM). Four aspects of QOL were examined: sexual activity; attitude towards the patients’ own body; relationships with other people; and occupational functioning. For the majority of persons with transsexism, QOL improved after surgery in terms of these aspects. All patients (100%) were satisfied with their GRS. However, only 20 patients (62%) were satisfied with how their bodies looked. In a study by Barrett, they used the General Health Questionnaire and assessments of depression inpatient groups. More controlled studies using this type of experimental design are needed to provide a better measure of surgical effectiveness.

For many patients undergoing GRS, their desire is to look ‘normal’ and be capable of having a normal sexual relationship. The results presented in this review have provided little evidence on how successful individual surgical procedures are in achieving these goals. Further research is needed to investigate these specific outcome measures of satisfaction and function.

In conclusion, we have confirmed the findings from previous reviews that the evidence to support GRS has several limitations in terms of: (a) lack of controlled studies; (b) evidence has not collected data prospectively; (c) high loss to follow up; and (d) lack of validated assessment measures. We have extended these findings from previous reviews by providing a summary of the evidence available for each of the ‘core’ procedures for MTF and FTM transsexism. In the majority of studies a large number of persons with transsexism experience a successful outcome in terms of subjective well being, cosmesis, and sexual function. We conclude that the magnitude of benefit and harm cannot be estimated accurately using the current available evidence.

This is a 2007 review of research on gender reassignment surgery. The authors found that there was not enough strong research to evaluate gender reassignment surgery; you can read more about the study as a whole here. This article looks more at specific surgical procedures.

The authors of the review evaluated individual surgical procedures rather than just looking at the outcome of all gender reassignment surgeries together. This allows a better understanding of which procedures are the most effective. It also means excluding some studies that looked at more than one procedure.

The authors reviewed all the articles they could find on specific gender reassignment surgeries from 1980 onwards. The review took place in October and November 2005.

The following are some of the results they found for specific surgeries. There is not enough data to definitively evaluate particular procedures and techniques, but there is useful information on possible complications. Clearly, however, we need more research.

Surgeries for Trans Women (born male)

Clitoroplasty/neoclitoris construction – The authors reviewed three studies that used a range of surgical techniques. The results were generally good but in one study 2 out of 10 patients had necrosis of the neoclitoris; in another study three out of nine patients did not report sexual satisfaction.

“All three included papers reported successful results in terms of function and cosmetic appearance with few or no complications (e.g. urine leakage). Rehman and Melman reported that the neoclitoris had remained intact postoperatively in eight out of 10 patients and the functional and cosmetic appearance was comparable to a normal clitoris. In two patients, however, the results were not satisfactory because of necrosis of the neoclitoris.

Using the dorsal portion of the glans penis with the dorsal neurovascular pedicle for clitoroplasty, the neoclitorides in nine patients survived well, and six patients reported sexual satisfaction. However, the transpositioning of glans on the long dorsal neurovascular pedicle appears to be a procedure with high risks.Overall, several studies have reported that the neoclitoris construction can result in good preservation of light touch and sexual sensation.“

Vaginoplasty/neovagina construction – The authors reviewed 32 studies. Satisfactory cosmetic and functional results were reported in many of the studies, although one found that “vaginoplasty combining inversion of the penile and scrotal skin flaps produced poor functional outcomes.”

In addition, according to the abstract of the 2001 study, “Minor complications, e.g. meatal stenosis in seven patients, occurred in 24 (36%) of patients. Ten patients with insufficient penile skin had the phallic cylinder augmented with a free-skin mesh graft, but in three of these patients an ileal augmentation was finally constructed because scarring occurred at the suture line between the penile skin and the augmented graft.”

At the same time, 47% of the patients in the 2001 study completed a follow-up questionnaire and almost all of them reported that they were “satisfied with the cosmetic result and capacity for orgasm.” Over half of the people who answered the follow-up questionnaire had had sexual intercourse.It is not clear if the satisfied group included the people who had had complications.

It would be good to have more information to compare to the German results. Are these rates of complications normal?

The reviewers did not find studies that met their criteria for labiaplasty, orchidectomy, or penectomy.

Surgeries for Trans Men (born female)

Hysterectomy – The authors only reviewed one study that met their criteria; it reported successful operations for two trans men. The study also reported that “a laparoscopic hysterectomy using the McCartney tube for FTM GRS was a useful procedure in overcoming difficulties encountered due to restricted vaginal access.”

Mastectomy – The authors reviewed three studies: “Colic and Colic found the use of a circumareolar approach for subcutaneous mastectomy produced flatter masculine breasts, leaving sufficient dermal vascularization for the nipple-areola complex. Of the 12 FTM patients all were very satisfied with the outcomes of surgery mainly because of the periareolar scar. It was reported, however, that two areolar necroses occurred due to perforation of the thin vascular dermal pedicle.”

Metoidioplasty – The authors reviewed two studies.

In the first, the procedure was successful for 32 patients with an average hospital stay of 11 days. One patient had a severe haematoma (solid swelling of clotted blood), but there were no other complications.

In the second study, 17 patients were satisfied with the size and appearance of their penis, but 5 people required additional augmentation phalloplasty. In two cases, the trans men developed urethral stenosis (narrowing of the urethra) and in three cases they developed fistula. The complications were related to the urethroplasty.

The reviewers add: “The metoidioplasty procedure produces a very small phallus (e.g. mean = 5.7 cm, range = 4–10 cm),hardly capable of sexual penetration, if at all. Only 10 of the 32 patients were able to void whilst standing. It should be noted that in the study by Hage et al, 18 patients combined the metoidioplasty procedure with the construction of a bifid scrotum in which testicular prostheses were implanted. Overall these two studies found metoidioplasty was an appropriate method where the clitoris seems large enough to provide a phallus and satisfies the patient.”

Phalloplasty – There is only limited data on the outcomes of phalloplasty, although two studies reported good outcomes in terms of size and stiffness and one reported good psychological outcomes.

However, there are a range of procedures and they have mixed results.

Serious complications have been reported and phalloplasty leaves a scar somewhere on the body.

One study found that creating the neourethra in two stages could reduce complications.

Another study using a suprapubic abdominal wall flap produced a good cosmetic appearance for 68% of the people; presumably 32% of the trans men had phalluses that did not look as good. A small study of using a lateral arm free flap reported good results.

“There appear to be limited data on outcome measures, including social integration, patient satisfaction and physiological function. Good operative results have been reported in terms of appropriate size and stiffness without vascular compromise and in terms of psychological outcomes. In addition to an aesthetically appealing look either while being nude (81%) or wearing a tight swim suit (91%), to void whilst standing appears to be an important goal for many FTM patients. It is important to recognize that there are a range of phalloplasty procedures available with mixed findings being reported in terms of effectiveness. Hage et al. reported several serious complications such as vesicovaginal, urethrovaginal fistulas and urinary incontinence. Furthermore, unlike the metoidioplasty procedure, free flap phalloplasty techniques produce extensive scarring to the donor site, unless techniques such as tissue expansion are used. Of the 85 FTM patients who had a phalloplasty fashioned from suprapubic abdominal wall flap that was tubed to form the phallus, Bettocchi et al. reported the cosmetic appearance of the phallus was considered good in 68% of the patients. Major complications (n = 60) were associated with the neourethra (75%), stricture formation (64%) and/or fistulae (55%). It should be noted that the complication rates found by Bettocchi et al. were significantly less (P < 0.001) when the neourethra was created in two stages. In contrast, Khouri et al. concluded by using a prefabricated lateral arm free flap technique it is possible to achieve a fully functional penis with stable long-term results and excellent patient satisfaction.”

Scrotoplasty/scrotum construction/testicular prosthesis – The authors reviewed two studies that met their criteria. “This procedure is generally accomplished by hollowing out the labia majora, inserting silicone implants, and attaching the labia to develop a single scrotal sac. Implant expulsion, rupture or dislocation is encountered in a small number of patients.”

Urethroplasty – The authors did not find any studies that met their criteria, but they reported that “A one-stage total phalloplasty and urethroplasty was associated with a significant rate of fistulas and strictures.”

The authors did not find studies that met their criteria for Salpingo-oophorectomy or vaginectomy/vaginal closure.

The authors conclude that “There is a need for good quality controlled trials based on clearly defined diagnosis and assessment criteria.”

And, “we have confirmed the findings from previous reviews that the evidence to support GRS has several limitations in terms of: (a) lack of controlled studies; (b) evidence has not collected data prospectively; (c) high loss to follow up; and (d) lack of validated assessment measures. We have extended these findings from previous reviews by providing a summary of the evidence available for each of the ‘core’ procedures for MTF and FTM transsexism. In the majority of studies a large number of persons with transsexism experience a successful outcome in terms of subjective well being, cosmesis, and sexual function. We conclude that the magnitude of benefit and harm cannot be estimated accurately using the current available evidence.”

This article is a good summary of surgeries used in medical transition. It is not a study or review of studies, but it is written by two experienced surgeons from the United Kingdom. They provide some numbers related to complications and some valuable information on specific techniques.

It is important to remember that this is not a scientific study or survey; it is a report by surgeons based on their experience. The results in other clinics may be different. If you are seeking surgery, ask your doctor about their work.

The authors’ discussion of sexual pleasure and orgasm is very limited. They do not discuss patient satisfaction. They do not look at the mental health effects of surgery, either, just the physical outcomes.

As always, there are many areas where we do not yet have any studies and we don’t know the answer. We could use more studies and articles about the various techniques, their outcomes, and their complications. Any evaluation of these techniques should include patient satisfaction and sexual function.

So what are the physical outcomes and complications of various surgeries that the authors discuss?

SURGERIES FOR TRANS WOMEN

Some Complications and Risks, Vaginoplasty

Death from pulmonary embolism – 1 in 1000 among recent patients at their clinic.

Pulmonary embolism (blood clot that travels to the lungs) – 2 in 1000 among recent patients at their clinic. The length of the surgery makes blood clots a problem; this clinic works to reduce them.

“MtF surgery can be complicated by all the normal nonspecific complications of major surgery. For instance, venous thromboembolic disease is a particular problem, partly owing to the nature of the operation (pelvic surgery), the prolonged duration of the operation (5 h in some units) and the practice, which is still common, of keeping patients on bed rest for several days after the operation. In our unit, the operative time is reliably in the region of 120–150 min and patients are mobilized immediately after surgery to reduce the risk of thromboembolism. Combined with routine use of low-­molecularweight heparins and compression stockings, we have seen only two pulmonary emboli in the last 1,000 MtF surgical procedures (one of which was fatal).”

Clinically significant bleeding – At least 10%. Most of the bleeding is from the “corpus spongiosum surrounding the urethra.”

“Specific to the operation itself, the most common complication of MtF surgery is bleeding. In units with large numbers, labial hematomas are seldom seen, but do occasionally occur. Most may be managed conservatively, but they do result in an increased incidence of wound dehiscence [opening up along the incision], as observed in our institution. The principle source of postoperative hemorrhage is from the corpus spongiosum surrounding the urethra. Even with meticulous suturing, some 10% of patients will experience clinically significant bleeds. This bleeding may be reduced by leaving the postoperative pressure dressing in place for longer, but that in turn can inhibit patient mobilization and may result in increased risk of thromboembolism.”

Fistula (hole) between the rectum and vagina – 6 in 800 at their clinic in 2008 – the numbers are unknown in general and possibly “seriously under-reported.” The cause is unknown.

Fistuals frequently require further surgery and sometimes lead to the removal of the neovagina.

“When a fistula occurs, a defunctioning colostomy is usually needed. About 50% of fistulas will then close spontaneously, but in the remainder further surgery is needed. In difficult cases, removal of the neovagina may be required.”

Narrowing of the urethra – 3-4% minimum rate. This problem causes “dribbling incontinence.” The narrowing develops a few months after the operation and requires surgery. The surgery is usually effective – “although a few do go on to long-term intermittent catheterization.”

Loss of vaginal depth and width – The authors give no numbers, but believe that these complications are under-reported. The loss of depth could be due to loss of skin; in this case a new vaginoplasty is required using using tissue from the bowel. Loss of depth and width could also be caused by not following a proper dilation routine.

“Again, these complications are probably markedly under-reported, as some patients are effectively celibate or do not need much vaginal depth and width for their chosen sexual activities.”

Growth of hair in the vagina – This is caused by not removing hair either before surgery or perioperatively. There is no cure; if your surgeon is using skin from the scrotum, be sure to have the hair removed.

“Once hair growth is seen in the vault of the neovagina, little can be done to prevent its continued growth, and a number of patients will have to return at intervals for removal of hairballs.”

Overall complicate rate – Under 25%. It is not clear exactly what complications they are including in this number.

Clitoroplasty

The authors don’t give numbers on orgasms or sexual satisfaction. In their experience, the vast majority of innervated neoclitorides have sensations.

Some surgeons create additional erogenous sensation by putting the part of the glans penis left after making the clitoris between the urethra and neoclitoris.

Past techniques led to problems with urethtral fistualas and leaking pee, but the techniques have changed.

“The rate of urinary leakage from urethral fistulas was substantial with this technique and it has now been largely superseded by techniques in which the neurovascular bundle to the glans, which lies between Buck’s fascia and the corpora cavernosa, is preserved. This technique has been widely described and seems to provide good rates of sensitivity and sexual satisfaction.”

Labioplasty

Creating labia minora is challenging. The best technique to use will depend on how much skin is left from the penis; this may vary depending on the individual and the surgery. There aren’t any guidelines on how to do this.

“Overall, a balance needs to be achieved between construction of a satisfactory neovagina, and a good, realistic, cosmetic external appearance. To date, no guidelines exist that give an indication of when and how penile or scrotal skin should be used for clitoral hood or labia minora reconstruction, or the ideal penile skin length, depth of the vagina or tissue that should be used. The choice of technique for labioplasty is, therefore, largely that of the individual surgeon.”

Urethrostomy

The authors describe one technique which has a low rate of immediate complications like bleeding, but can lead to peeing upwards or narrowing of the urethra. In addition, this technique leaves in place some erectile tissue that swells during sexual arousal.

The authors prefer a different technique which creates a satisfactory direction of pee and which they believe looks better cosmetically. However it has a raised risk of bleeding.

Specifically, with the first technique they “divide the urethra in the proximal bulb and suture the urothelium direct to the skin (bringing the urethra through the anterior skin flap)” and with the second they “spatulate the urethra, and excise some or all of the corpus spongiosum posterior to the urethral meatus.”

Breast augmentation in trans women is similar to breast augmentation in cis women, but will be affected by the shape and size of the starting breast tissue and muscles.

Speech therapy is required after vocal cord surgery.

“In facial feminization, good results are achieved by shaving of the frontal bossae, the brow ridges, the mandible angles and the chin, accompanied sometimes by rhinoplasty.”

SURGERIES FOR TRANS MEN

Some Complications and Risks, Metoidioplasty

One of the advantages of a metoidioplasty is that there are few complications and recovery time is “quick.”

“The complication rate is relatively low (overall complication rate <20%)—especially when compared with more elaborate microsurgical techniques, in which complications are reported in 40% of patients.”

The disadvantages of this type of surgery are that it produces a short phallus that may not be capable of sexual penetration. Not everyone can pee standing up.

On the other hand, sexual sensations are well preserved which is a pretty important factor. The authors don’t compare metoidioplasty and phalloplasty in terms of sexual pleasure for the trans man.

“…micturition in a standing position is somewhat, but not always, achievable. Despite the small size, some patients report satisfactory intercourse with female partners, and sensation is usually well preserved. Nevertheless, this approach is not well suited to individuals in whom clitoral hypertrophy is less marked, and the small size of the resultant phallus is unsatisfactory for most patients, not least because it is inadequate to show in clothing and for satisfactory sexual penetration.”

Are they trying to cause dysphoria here? I don’t think there are any numbers on what percentages of trans men prefer which form of surgery.

Some Complications and Risks, Phalloplasty

Overall complication rate – Over 40%. it is not clear exactly what complications they are including.

Microsurgical flap failure – Less than 2%.

Fistulas involving the neourethra – 25-30% in most series.

“Most fistulas will eventually close after a period of catheterization, but many require revision surgery.”

Urethral stricture formation (narrowing of the tube that carries pee out of the body) – 18%.

Postmicturition dribble (dribbling after peeing) – In one study, 79% of patients reported this problem.

Erectile function – Most phalloplasty techniques require the insertion of an inflatable prosthesis to become erect for sexual activity. “…the failure rate for penile prostheses is considerable, usually owing to infection of the device…”

We don’t know much about this yet. “Long-term results on the use of these erectile implants in FtM transsexuals is still lacking.”

There are some techniques that do not require a prosthesis, but they may have other issues.

“When a latissimus dorsi myocutaneous free flap is used, sexual intercourse is possible by contraction of the muscle, which stiffens, but shortens, the penis without requiring a prosthesis. Flaps harvested with bone (for example, fibula or osteocutaneous radial forearm flap) do not need stiffeners, but this flap type results in a permanent erection.”

Sexual sensation – For free-flap phalloplasties, “Sexual sensation with retention of ability to orgasm is usually preserved.” The authors don’t compare metoidioplasty and phalloplasty in terms of sexual pleasure for the trans man.

Different techniques – There are a few different techniques for phalloplasty, but we don’t have any studies comparing them to see which ones are best.

“To date, the gender team at Ghent University Hospital, Belgium, has published the largest series on phalloplasty (with radial forearm flap technique). The investigators demonstrated that the radial forearm flap is a reliable technique, although evidence that other techniques are similarly reliable, or even better than the radial forearm flap, is lacking.”

Mastectomy

An earlier review found few studies of mastectomies specifically for trans men. However, as the authors note here, it is important to have a surgeon experienced in mastectomies for trans men. The surgery is not the same as it is for women.

The authors give no numbers on complications but note that people often need minor revisions for cosmetic reasons.

The authors provide a few notes on techniques:

“The exact technique will depend on the volume of breast tissue, and the skin excess and elasticity. In small breasts, a satisfactory result may be achieved by subcutaneous mastectomy via a circumareolar incision, but in most patients more extensive surgery, with additional noticeable scars, is required. For very ptotic breasts, a breast amputation with free nipple– areola complex graft is indicated. Finally, the nipple itself and the diameter of the areola are often reduced. When done properly, the results may be very satisfactory, but poor technique can lead to unacceptable cosmetic results. Minor revisions to ameliorate the final cosmetic outcome are often required.”

Other Surgeries for Trans Men

For scrotal reconstruction, “As long as this advancement of the neoscrotum to the natural position in front of the legs is carried out, very satisfactory results can be obtained with no major complications.”

The authors say patients should get their uteruses and ovaries removed. They don’t provide any additional information on the procedures.

“Patients will also require hysterectomy and ovariectomy, because of the potential risk of endometrial carcinoma with protracted testosterone use, and are usually accomplished laparoscopically at the time of one of the stages of subsequent phalloplasty. The short blind-ended vagina can be left in place or removed.”

We could use more studies and articles on all of the above surgeries.

AUTHORS’ CONCLUSIONS

“Gender reassignment surgery—in which elective surgery is performed to alter an individual’s body to resemble the other sex and in doing so adapt the body to the patient’s perception and lifestyle—is one of the most challenging surgical disciplines.

In MtF surgery, the technique is largely standardized, but refinements are needed to satisfy specific patient requests, such as vaginal depth and ‘perfect’ cosmetic outcome.

In FtM surgery, the variety of techniques available demonstrates that the ideal technique has not yet been identified and, depending on a patient’s request, a different surgical approach should be used. Furthermore, very few centers have the experience of, and subsequently can offer, different techniques for FtM gender reassignment. Moreover, complications are frequent and limitations to the ideal reconstruction are present with every technique used.

The complex psychological background of the patients and their expectations further challenge gender reassignment surgeons. The cooperation of the gender team in making a diagnosis, selecting appropriate patients for surgery, and deciding timing and type of surgical procedures to be performed, is crucial in reducing patients’ regrets or minor dissatisfactions (at both physical and psychosocial functioning levels) as a result of possible complications or for not having achieved the result expected.”

This is a case study of a trans man (born female) with many serious mental health problems, including an eating disorder. He was a survivor of childhood sexual abuse and the trauma seems to have been at the root of his problems.

This case study does not make any connections between his eating disorder and his gender dypshoria. Given the abuse and the multiple comorbidities, it is unlikely that the gender dysphoria caused the eating disorders.

The authors suggest that both the eating disorder and the gender dysphoria were caused by the early trauma.

“the underlying foundation of these multiple diagnoses is the presence of early developmental trauma to the emotion regulation system — which manifests as physical and emotional pain with impulsive and maladaptive attempts to engage in behaviors to meet personal needs, including safety. Zanarini and colleagues performed a study examining Axis I comorbidity in patients with BPD [borderline personality disorder] and identified high rates of comorbid PTSD. They also observed that meeting criteria for multiple Axis I disorders predicted meeting criteria for BPD.”

Medical transition came later and was not part of the recovery from the eating disorder. However, at the time the patient entered therapy, he had already taken a male name and was dressing and living as a male.

This case study has some similarities to the case of a teenage girl* who developed gender dysphoria while being treated for an eating disorder. The teenage girl was also a survivor of childhood sexual abuse with multiple mental health problems: anxiety, depression, an eating disorder, excessive exercise, and OCD-type rituals related to germs (spraying her body with Lysol and excessive hand-washing). In addition, she had a past history of PTSD, OCD, self-harm, and suicidal thoughts.

These two cases suggest that in some cases, gender dysphoria is not the main cause of an eating disorder. Rather, trauma causes multiple mental health issues.

There are two more case studies of transgender people with eating disorders who were survivors of child abuse. They suggest different possible conclusions, however.

A trans woman whose eating disorder began when she started to live as a woman. Her goal was to have a more feminine shape. Transition and hormones did not cure the eating disorder, however. She had been physically and sexually abused as a child.

A trans woman whose identical twin also had an eating disorder. Both twins were feminine in behavior from a young age and both were sexually attracted to men. Both survived an abusive father who threatened them with assault and death. However, one was a trans woman and one was a gay man.

In the first case, the eating disorder seems to be closely connected to the gender dysphoria since it started when she began to live as a woman. She clearly describes wanting to look more female. The abuse may have affected her, but gender dysphoria was also a factor.

In the second case, the eating disorder seems to have been caused by a combination of genes and environment, since both twins had anorexia but only one had gender dysphoria.

We’re left with the possibility that the answer is different in different cases. Sometimes severe childhood trauma may cause multiple mental health problems that include an eating disorder. Sometimes a combination of gender dysphoria and early childhood trauma may contribute to an eating disorder. And sometimes the same genes and environment will produce two people with similar eating disorders but different gender identities.

Of course, these are only four case studies. We can’t draw conclusions from them about all transgender people with eating disorders. Most of the case histories I have found don’t mention child abuse. Many of them suggest connections between gender dysphoria and eating disorders.

What we can see from these cases, however, is that for some transgender people with eating disorders, gender dysphoria is not the main or only cause of their eating disorder. Therapists should keep this in mind when treating transgender patients for eating disorders.

The article provides an interesting discussion of diagnosing and treating a patient. The full text is available online without cost, but here are a few details of the case:

The trauma the trans man survived involved “repeated episodes of sexual violence perpetrated from age 4 to 9 years old by a childhood friend’s father in the neighborhood.”

…

“The patient believed he had suffered multiple head injuries related to physical violence and asphyxiation in the context of sexual trauma, but was unclear if he had lost consciousness because of head injury or because of psychological dissociation during these events.”

…

He had “a history of heavy chemical use, starting with first use of alcohol at age 7, which continued through age 23. He also used diet pills starting at age 14, followed by heavy use of cannabis at age 15, and cocaine and other narcotics, including pills and heroin, at age 18 years.”

…

The patient had severe pelvic floor dysfunction which caused him a great deal of pain. It took him a while to get this diagnosed correctly.

…

“The patient was born and raised as a female, but in retrospect realized he did not fully identify with either the male or female gender. In the previous 2 years, he had decided to openly adopt a male gender, name, and manner of dress. He had the intention of pursuing hormone therapy and, eventually, chest reconstruction.”

…

Treatment and afterwards:

“Suicidal thoughts and behaviors were identified as the highest-priority target; after 6 months, these thoughts and behaviors had resolved. The patient was engaged in therapy and did not require significant emphasis on therapy interfering behaviors; therefore, quality-of-life interfering behaviors could be targeted, including purging behaviors, urges to use substances, self-injury, self-care, and interpersonally effective behaviors with friends, family, and other medical professionals. He graduated phase 1 of DBT therapy and proceeded to phase 2 to continue working on healthy emotional experiencing and management of trauma sequelae.

The patient graduated college with a high grade point average and went on to pursue master’s level education. He underwent sex hormone treatment and chest reconstruction.

He developed additional medical comorbidities, including insulin resistance and adrenal insufficiency. These medical conditions necessitated moving back in with his parents, resulting in significant familial conflict. The patient’s therapist made a referral for family therapy through our department, which was coordinated among treatment providers. The patient is enthusiastic about the progress made in treatment and states he often wonders if he would be still be alive without the intervention he received. Over the course of 3 years, his medications were all tapered to discontinuation, with the exception of prazocin 10 mg at bedtime for nightmares, ramelteon 8 mg for sleep, and clonazepam 1 mg three times a day, which was continued to assist with pelvic musculature functioning.”

This is a qualitative study of eating disorders and gender dysphoria. Its strength is that the authors asked transgender people themselves what they thought. Its weakness is that we can’t draw many conclusions from it, although we can use it to find questions for future research.

Limits of the Study

We can’t use it to estimate the prevalence of eating disorders among trans people. The participants were recruited for a study of body image and eating behaviors. Transgender people with eating disorders may be more likely to volunteer for such a study.

We can’t use it to collect statistics on trans people with eating disorders because the data is not uniform. Participants were asked open-ended questions, so we can’t be sure what it means when they give different answers. For example, one person talked about wanting to control his body. Did other participants agree with him and not think to mention it or did they just not care about controlling their bodies?

We can’t look at how individual eating disorders and gender dysphoria developed over time because we don’t have case histories of the participants.

The participants in the study were not formally diagnosed with eating disorders; the data on their eating is self-reported, although convincing. It is not clear from the study how many of the participants currently had symptoms of disordered eating.

On the other hand, we do have some data we can use from this study.

Data from the Study

The authors found 14 people with gender dysphoria who reported current or previous disordered eating and/or excessive exercise.*

About half of the transgender people with an eating disorder talked about gender dysphoria causing their eating disorder and about half did not.**

Other explanations given for the eating disorder included self-control, feeling like an outsider, struggle for autonomy, feeling that one did not deserve to eat, psychological stress and strain, and a belief that being thin would make sexual situations easier.

Explanations related to gender could be classified as efforts to suppress gender or efforts to accentuate gender.

A few participants talked about the relationship between disordered eating and transition. Some saw hormones as positive and some saw them as negative:

Two trans men (born female) said that hormone therapy had helped them to stop caring about their weight.

Two trans women (born male) said that hormone therapy had made them gain weight. (One of the women who said this was waiting for diagnosis and hormone treatment; presumably she was self-medicating.)

One woman who was considering gender reassignment said that breast reduction surgery had helped her stop caring about her weight.***

There was no clear relationship between medical transition and current scores on subscales of the Eating Disorder Inventory-3.**** The three people with the highest total scores included:

Two trans women who had had genital surgery and were on estrogen – the surgery means that their bodies were no longer producing much testosterone; and

One trans men who was taking testosterone and waiting for a mastectomy.

You can read further details of the study below the footnotes.

Future Research

The data we can get from this study isn’t much, but it does point to some important questions for future research. Many of these are questions raised by case studies as well.

What do transgender people see as the main cause of their disordered eating? Do they see it as being about issues like control, autonomy, and stress or do they see it as being related to gender dysphoria? Or both?

Is affirming the desired gender or suppressing biological sex a more important factor in disordered eating? Do trans men and trans women give different answers to this question?

Are there differences between the group of people who see their eating disorder as being related to gender issues and those who do not? Do they have different patterns in terms of when their symptoms of disordered eating developed, what their symptoms looked like, or what happened when they transitioned?

Do people’s perceptions of what causes their disordered eating match reality? Do they have relatives with eating disorders, for example? Were there other factors in their life that might have contributed to the eating disorder? When did the eating disorder develop?

How does the relationship between the eating disorder and gender dysphoria affect recovery from the eating disorder?

When did the disordered eating begin in relation to the gender dysphoria? How did the two conditions develop over time?

Does transition increase or decrease symptoms of disordered eating? Does it have no effect?

Are the effects of transition on eating disorders different for trans men and trans women? In this study, two trans men with eating disorders felt hormone therapy helped their recovery, while two trans women said it made them gain weight.

Trans women and trans men are not getting the same treatment for gender dysphoria; how does that affect eating disorders? In this study, trans men had mastectomies while trans women had genital surgery. Mastectomies might be more important in issues related to body shape. In addition, hormone therapy would have involved completely different medications for trans men and trans women.

Do the hormones themselves play a role in eating disorders, either reducing or increasing symptoms?

Comparison to Case Studies

Prevalence of eating disorders in trans men versus trans women

In this study, slightly over half of the participants were trans men. Trans women were not more likely to have eating disorders than trans men. In contrast, the case studies are overwhelmingly of trans women with eating disorders. What is the real prevalence of eating disorders among transgender people? Is there a difference in the rates among trans men and trans women or not?

It might be that selection bias means that case studies of trans women with eating disorders are written up more frequently. Eating disorders are relatively rare among biological males and potential authors of case studies might notice them more. Conversely, it might be that trans men were more willing to volunteer for the study than trans women or that a group of trans men encouraged each other to participate.

The link between eating disorders and gender dysphoria

Some case studies suggest that factors other than gender dysphoria are central in the development of disordered eating. We have the case of the identical twins who both had anorexia, although only one was transgender. Similarly, the trans man with an eating disorder in this case study had two cousins with eating disorders and this boy’s mother had had anorexia. Then we have the case of the teenage survivor of sexual abuse with PTSD, generalized anxiety disorder, OCD, an eating disorder, and a history of self-harm. The teenager developed gender dysphoria while being treated for her eating disorder; it may be that the trauma was the most important factor in all of her problems.

On the other hand, we have five cases of trans women whose eating disorder began when they decided to live as women, reported in this case study, this one, this one, and this one. In addition, in this case study, one trans woman’s eating disorder seems to have begun at the same time as depression related to her gender.

We also have a couple of case studies where trans men say that their disordered eating was a desire to get rid of feminine features; in this case his curves, breasts, hips, and feminine face and in this case his period and feminine shape. However, in the first case, the trans man also had two cousins with eating disorders.

There is also this somewhat unusual case of an underweight boy with poor eating habits who developed severe anorexia after a doctor suggested that he take testosterone to induce puberty. Again, in this case, his mother had also had anorexia.

Intriguingly in these two cases, gender identity seemed to affect the patient’s symptoms, but not the underlying dissatisfaction with their bodies. In the first case, the patient had a fluid gender identity; when he lived as a man he tried to gain weight and muscle, when he lived as a woman he tried to lose weight. His habits were always pathological and he always hated his body. In the second case, the patient initially identified as a woman. After coming out as gay to supportive friends, he identified as a gay man; as a woman he dieted and as a man he tried to gain muscles.

Of course, since they are case studies, there could be some selection bias. People might be more likely to report cases where gender identity seemed to have affected the eating disorder – or they might be more likely to report cases that are unusual like identical twins and fluid gender identity.

This is where this study is helpful; we see that a number of transgender patients did not bring up gender issues when asked what they thought caused their eating disorders. We also see that some patients thought gender issues were important causes. And now we need another study to find out what that means.

The effect of transition on gender dysphoria

This study found one person considering transition who said that breast reduction surgery had helped her with her disordered eating,

In contrast, there are three individual case studies where sex reassignment surgery contributed to an eating disorder. This trans man began binging and purging for the first time after having his breasts, uterus, and ovaries removed. One of the trans women in this study had an eating disorder in adolescence; her symptoms returned after sex reassignment surgery 20 years later. Finally, this adolescent trans man recovered from an eating disorder and transitioned; after his mastectomy, he began to relapse and ten months later he returned to the clinic for eating disorders.

In the qualitative study two trans men said that hormone therapy had helped them with their eating disorders, while two trans women said hormones had made them gain weight.

On the other hand, two trans women and a trans man who were taking hormones had relatively high scores on three subscales of the Eating Disorder Inventory-3. The two trans women had already had genital surgery (which would have included removing their gonads) while the trans man was waiting for a mastectomy.

Looking at the case studies, there were two trans women with eating disorders who were already on hormones (here and here), although one of them does not seem to have been interested in recovering from her disordered eating. There was one trans woman who believed that transition had cured her, but she was severely underweight, even more so than she had been before transition. In addition, the patients listed above who had problems with their eating after sex reassignment surgery were also on hormones, although it could still be that hormone therapy initially helped them.

On the other hand, there was one trans man whose eating disorder was cured by taking testosterone. In addition, taking puberty blockers helped this adolescent trans woman restore her weight, although, of course, puberty blockers are not the same as hormone therapy for trans women or trans men.

In many of the case studies, patients recovered from disordered eating before they were referred to a gender clinic.

It seems clear that we can not rely on transition to cure an eating disorder and at times it may exacerbate it. Therapy for eating disorders should be aimed at the eating disorder and patients with gender dyshporia and eating disorders should have follow-up care for the eating disorder after they transition.

You can read further details of the qualitative study below the footnotes.

*I count 16 people with an eating disturbance or excessive exercise, according to their Table 2. I’m not sure if this is a typo or if two people reported symptoms that were not considered severe enough to be an eating disorder.

**It is difficult to tell from the study how many people identified gender dysphoria as a cause of their eating disorder. The study talks about 5 people who were suppressing their gender and 3 people who were accentuating their gender, but the two groups overlap. They quote one person twice for both suppressing and expressing their gender. There is no list of which people talked about which possible causes for their gender dysphoria, so there could be more overlap.

Based on the quotes they include, at least seven and possibly eight people mentioned something to do with gender as a possible cause of their eating disorder. This means at least six or seven did not.

It is also possible that some of the people who mentioned gender dysphoria as a possible cause of their eating disorder also mentioned other possible causes. Or that some people did not answer the question.

*** There was also one trans woman (“Julie”) who felt that genital surgery had made her less self-conscious about her body and her weight. However, she had never had any symptoms of an eating disorder or excessive exercise. Her case does not answer the question of how eating disorders may be related to gender dysphoria, especially since there is a group of people with eating disorders and gender dysphoria who did not say that gender issues affected their eating.

****The participants were tested on the Drive for Thinness, Bulimia, and Body Dissatisfaction sub-scales of the Eating Disorder Inventory-3.

More Details on the Study:

Eating Disorders and Gender Dysphoria

The authors found 14 people with gender dysphoria who reported current or previous disordered eating and/or excessive exercise. Looking at their Table 2, I count 16 people with disordered eating and/or excessive exercise, but perhaps there were two cases where the symptoms were not severe enough to be considered disordered.

Of these 14 people, seven or eight mentioned gender as a cause of their eating disorder or excessive exercise (see footnote above as to why the number is unclear). This included 6 or 7 trans men and 2 trans women.

Six or seven people did not mention gender as a cause of their eating disorder or excessive exercise.

Other explanations given included self-control, feeling like an outsider, struggle for autonomy, feeling that one did not deserve to eat, psychological stress and strain, and a belief that being thin would make sexual situations easier.

“I have always wanted to feel that I can control my body.”

“I have felt like I was an outsider since I was little. I have felt inadequate, like I don’t belong to the group, and because of that any criticism about what was most essential to me, my body and how desirable I am, was a really serious thing to me.”

“At that age [eating] was really the only thing I could have an influence on.”

Explanations related to gender fell into three categories –

suppressing gender (“The background of that crazy weight loss was that my curves would disappear”),

accentuating gender (“It is easier to make a man’s body look feminine if you’re a bit thinner”), and

enhanced masculinity (“[After losing a lot of weight] I could buy pants at the men’s department, and they fit in a certain way, the right way, as I see it.”)

Four trans men mentioned suppressing gender, one trans man mentioned accentuating gender, and one trans man mentioned enhancing masculinity. It is possible that there is some overlap between the categories.*

One trans woman mentioned accentuating gender and one trans woman mentioned both accentuating and suppressing gender as possible causes of disordered eating.*

Eating Disorders and Transition

The authors identified sixteen people who had already begun hormone therapy and/or had surgery. In addition, one trans woman seems to have been self-medicating and one trans man had already had breast reduction surgery. Of these 18 people:

Two trans men said that said that taking testosterone had helped them recover from their eating disorder; they stopped caring about weight gain.

Two trans women said that taking hormones caused weight gain and in one case, problems with blood sugar. It is not clear exactly which medications they were talking about – estrogen and blockers or just estrogen. One of the trans women who said this was waiting to begin hormone treatment, so presumably she was self-medicating.

One woman who was considering gender reassignment said that breast reduction surgery had helped her recover from her eating disorder. She no longer cared about weight gain after the surgery.

One trans woman said that after genital surgery she felt comfortable in her body and didn’t care about any fat. However, she had never had any symptoms of disordered eating or excessive exercise, so this may not be relevant to people with eating disorders.

Current Scores on Subscales of the Eating Disorder Inventory-3 (EDI-3)

The study does not separate data on current symptoms of disordered eating and excessive exercise from data on past symptoms. However, the study participants completed three subscales from the Eating Disorder Inventory-E (EDI-3): Drive for Thinness, Bulimia, and Body Dissatisfaction.

We can not use the scores on three subscales of the EDI-3 to diagnose an eating disorder, but they may give some indication of how the participants are doing now.

Of particular concern are “Sue,” “Martha,” and “Leo.” Sue and Martha are trans women who had had genital surgery and were on hormones. Leo is a trans man who was on hormones but was waiting for a mastectomy.

Sue scored 16 on the drive for thinness scale, 17 on the bulimia scale, and 21 on body dissatisfaction. Martha scored 9 on the drive for thinnness scale, 9 on the bulimia scale, and 22 on body dissatisfaction. Leo scored 14 on the drive for thinness scale, 11 on the bulimia scale, and 34 on body dissatisfaction. The three of them had the highest total scores compared to any of the other study participants.